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Waste Tire S6, Bey & Inspection Report Inspection Report Number <br /> CalRecycle <br /> State of California <br /> CalRecycle 181(Rev. (Cal Survey Form - Pale 11 - 1230419 <br /> Dept.of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLUE OR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- � ` 1 � � � � � � � Inspection Type(Fill one) <br /> p Q Q <br /> Site Suffix: b Routine Re-inspection Referral Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: 65"Y" Q CHP Q CalRecycle Q Complaint Q Educational Visit Q Other <br /> Business or Facility Name <br /> � Inspected By Inspector <br /> Physics A^7ddress ! l <br /> MA-r- 7Q <br /> �` 9 q5�l Inspection Date O q / -2 9 / <br /> i va-t", Time In Time Out <br /> Business Re( Title *AM l _. : l � O Al <br /> t"'�Yr1tJ. 1 60 RC1 W VV_ I I ® Q PM ®PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) <br /> 3 (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0&Active III Passenger ® Generator 0 Outdoor2OM <br /> O Q Closed Q Altered <br /> GPS Latitude Q Hauler 0 Indoor 176 <br /> O Q Inactive • Truck <br /> Longitude - Q Planned 0 OTR Q End-Use Q Container <br /> Business Type(Fill all that apply) <br /> Q New Tire Dealer Q Auto Repair Trucking Fleet Q Government Q Retreader Q Dismantler Q Tire Derived Fuel <br /> Q Used Tire Dealer Q Auto Body Q Car Dealer Q Collection Q Crumb Rubber <br /> Q Service Station Q Hauler Q Agriculture Q Shredder 0 Other AjE9ki-."c - <br /> Part B - Inspecti n of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> Q Notice Of Violation Q Extension <br /> Q Q <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> Q Q PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> Q Q PRC§42956-Registration/Decal in Vehicle <br /> Q Q 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m / m / m <br /> Q Q 14 CCR§18459.1 -Tire Program ID Number from CalRecycle 9 <br /> Q Q 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EXT) N <br /> Q Q 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years o <br /> Q Q 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers Q Referred/CalRecycle Enforcement <br /> LU <br /> Q Q 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities W <br /> Q Q 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators •In Compliance-No Violations o <br /> Q 1 Q 1 Other:§ <br /> z <br /> Comments 1 '�atkyA <br /> N <br /> chfts aP <br /> Inspection Form Included: Q <br /> Comments Included: v <br /> Busines Signature Phone Num er Inspect is Signature Phone Number <br /> INSTRUCTIONS ON BACK Correct: Incorrect: E X A M P L EI 111273 62081 <br /> ® White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />